Otolaryngology-Head & Neck surgery

Elizabeth Tadesse (MD,Otolaryngology)

 Introduction
• Otolaryngology is the specialty that deals with
diseases of the head and neck region(the
region from the clavicle up)
• The specialty originally included the treatment
of eye conditions and was commonly
identified as EENT (eyes, ears, nose, and
throat).
• ENT conditions 25-50% of general practice
consultations.
 Contd…
• What is an Otolaryngologist-Head & Neck Surgeon?
 Specialist that treats disorders of the head and neck both medically and
surgically
 More of a tertiary care specialist
• SCOPE of practice
OTOLOGY /NEUROOTOLOGY
RHINOLOGY
LARYNGOLOGY
HEAD AND NECK SURGERY/ONCOLOGY
FACIAL PLASTIC & RECONSTRUCTIVE SURGERY
SKULL BASE
AUDIOLOGY
SLEEP MEDICINE
PEDIATRIC OTOLARYNGOLOGY
 Learning aims and objectives
• To provide students with an appropriate background covering the
common and important ENT emergencies and diseases as well as related
head and neck disease in children and adults &when and what to refer.

• To understand that ENT problems are extremely common and form a

large part of the OPD visits.

• Enable students obtain a detailed history from patients and experience

clinical ENT and head and neck examination and make a presumptive
diagnosis

• Be familiar with recent methods of diagnosis and proper management

and indications of specialist referral
 Course content
 Ear(otology) and Neurotology

 Nose and Paranasal Sinuses (Rhinology)

 Oral cavity and Pharnyx(oro,Naso and Hypopharnyx)

 Laryngology

 Salivary glands

 Neck
THE EAR
 Temporal bone anatomy
• articulates with the
sphenoid, parietal, occipital,
and zygomatic bones,
contributing to the skull
base, and facial structure.
• temporal bone consists of
four embryologically
distinct components:
• the squamous, mastoid,
petrous, and tympanic parts
 Contd…
• The squamous part forms the
lateral wall of the middle
fossa.
• Mastoid part is a bulbous
bony structure shaped by the
expansion of air-filled spaces
• The petrous part has the
shape of a pyramid whose
base is united with the
mastoid laterally.
• The petrous apex is oriented
anteromedially between
occipital and sphenoid bones.
 Ear Anatomy

 External Ear
 Middle Ear
 Inner Ear
I. External ear- the
auricle, the external
canal and tympanic
membrane.
 The auricle(pinna)

• Part of external ear that

projects from the side of the
head
• has characteristic
prominences and depressions
• body of the auricle is formed
from elastic fibrocartilage and
is a continuous plate.
• cartilage of the auricle is
covered with perichondrium
 The external auditory canal

• extends from the concha of

the auricle to the tympanic
membrane
• ~ 2.4 cm
• Cartilage in the lateral 1/3 and
bone in the medial 2/3
• diameter of the canal varies
greatly b/n individuals and
between different races.
• In adults it runs inwards
slightly downwards and
forwards.
 EAC(Cont’d)
• two constrictions:
• at the junction of
the cartilaginous
and bony portions
• At the isthmus, 5
mm from the
tympanic
membrane.
 EAC(Cont’d)
• The skin of the cartilaginous canal
contains many hair cells and
sebaceous and Ceruminous
(apocrine) glands.
-The apopilosebaceous unit.
• Glandular secretions combine with
sloughed squamous epithelium to
form a coat of cerumen.
• the primary barrier to infection….
-Hydrophobic, waxy, acidic coating
-Contain lysozyme and
immunoglobulin G
 Tympanic Membrane/Ear drum
• forms the partition between the external
acoustic canal and the middle ear
• consists of three layers
(i) Outer epithelial layer
(ii) Inner mucosal layer
(iii) Middle fibrous layer
• Has two parts
(a) Pars Tensa
• It forms most of tympanic membrane
• Central part is called the umbo
(b) Pars Flaccida (Shrapnel's Membrane)
• situated above the lateral process of
malleus
• Less sparse fibrous tissue
 Contd…
• 9-10 mm by 8-9 mm in dimension and 0.1mm thickness
• Most of the circumference is thickened to form the
tympanic annulus.
• Innervation :
(i) Anterior half of lateral surface: auricu lotemporal (V 3)
(il) Posterior half of lateral surface: auricular branch of
vagus (CN X):
(iii) Medial surface: Tympanic branch of CN IX (Jacobson's
nerve)
 Contd…
Nerve Supply of the External Ear:
Pinna
(i) Greater auricular nerve(C2,C3)
(ii) Lesser occipital (C2)
(iii) Auriculotemporal (V3)
(iv) Auricular branch of vagus (CN X),
also called Arnold's nerve
(v) Facial nerve
External Auditory Canal
(i) Anterior wall and roof: auriculotemporal (V3)·
(ii) Posterior wall and floor: auricular branch of vagus,
(CN X)(Arnold’s Nerve)
(iii) Posterior wall of the auditory canal also receives sensory fibers of CN VII
Q: why do some patients cough during otoscopy?
 II. Middle ear cleft

• consists of the tympanic cavity, the

Eustachian tube and the mastoid air
cell system.
• The tympanic cavity or middle ear
is an irregular, laterally compressed
space in the petrous part of the
temporal bone. It is lined with
mucous membrane and filled with
air.
 The ossicular chain
 Nerves of the middle ear-The chorda
tympani and the tympanic plexus
 Muscles of the middle ear
*Stapedius
*Tensor tympani
Contd…
 Relations
Contd…
 The roof is formed by a
thin plate of bone called
tegmen tympani.
 The floor is also a thin
plate of bone which
separates tympanic cavity
from the jugular bulb
 The anterior wall has a
thin plate of bone which
separates the cavity from
internal carotid artery
• has opening; for the
eustachian tube
 Contd…
 The posterior wall lies close to
the mastoid air cells and the
sigmoid sinus.
 Aditus,an opening through
which middle ear communicates
with the antrum.

 The medial wall is formed by the

labyrinth.
• presents the oval window and
round window
 The lateral wall is formed largely
by the tympanic membrane.
 Contd…
Ossicles of the Middle Ear
• Three ossicles in the
middle ear- the
malleus,incus and
stapes.
• conduct sound energy
from the tympanic
membrane to the oval
window.
 Contd…
Mastoid
–It contains air filled cavities lined
by mucous membrane.
– The air cells are arranged in
groups(antrum is the largest).
--The sigmoid sinus is posterior,
and separated from the
antrum by mastoid air cells.

• The mastoid air cells, are not

well developed at birth.
 Contd…
Eustachian Tube:
• connects nasopharynx with the tympanic cavity
• In an adult, it is about 36 mm long and runs downwards, forwards
and medially from its tympanic end, forming an angle of 45° with
the horizontal.
• N.B: In infants- wide, short and horizontal.
 The lateral third – bony
 The medial two-thirds -cartilaginous part

• Closed at rest but opens swallowing and yawning

• Function –equalize air pressure, protection and drain the middle
ear.
 Contd…
• Nerve supply of the middle ear
I. Sensory- by tympanic plexus
• formed by the tympanic branch of the
glossopharyngeal nerve (Jacobson’s nerve)
II. Motor supply
 Facial nerve- the stapedius muscle
 Mandibular nerve- supply the tensor
tympani muscle.
 Contd…
III. Inner ear (labyrinth)
 Vestibular portion and cochlear portion
a) Bony labyrinth
 The bony cochlea: is a coiled tube making 2.5 to 2.75
turns round a central pyramid of bone called the
modiolus.
 The bony vestibule:
-Three semicircular canals: lateral, posterior and
superior, and lie in planes at right angles to one another.
-Bony Saccule and utricle
Contd…
 Contd…
b) Membranous labyrinth
• consists of the cochlear duct, the utricle and saccule, the
three semicircular ducts, and the endolymphatic duct and sac.
– The cochlea is responsible for hearing , sensory organ is organ of
corti .
– The semicircular canals (sense organ –crista ampullaris), utricle and
saccule( sense organ- macula) are responsble for maintaining
balance.
• The nerve responsible for these functions is the
vestibulocochlear nerve [VIII], which divides into vestibular
(balance) and cochlear (hearing) parts after entering the
internal acoustic meatus.
Blood supply
 Physiology of hearing & balance
• The pinna collects sound waves and directs
them into the external auditory canal.
• Its shape helps to localize sound direction and
amplification.
• The EAC helps in transmitting sound waves to
the eardrum or tympanic membrane.
• The middle ear is to transduce sound waves,
amplify them, and pass them to the cochlea.
 Conductive pathway
 Sound energy from the air to
the inner ear.
 Auricle-TM-the ossicles
Impedance matching
mechanism:
 TM and ossicles provide
hydraulic(area) advantage
and a lever effect
• Area advantage: 17:1
• Lever effect: 1.3:1
 Transformer ratio: 22:1 or
approx. 25-30 dB gain
 Sensory neural pathway

• Transduction of mechanical energy to electrical

impulses (sensory system of cochlea).
• Conduction of electrical impulses to the brain
(neural pathways).
Neural pathways(ECOLI-MA)
 Balance
• Vestibule’s main function is to sense head movements and
counter them with reflexive eye movements and postural
adjustments.
• It senses head movement and sends that information to neurons
in the brainstem vestibular nuclei.
• Secondary vestibular neuron signals diverge to other areas of the
CNS to drive vestibular reflexes
 ocular motor nuclei —vestibulo-ocular reflex( stabilizes gaze )
 cervical spinal motor neurons — vestibulocolic reflex
 lower spinal motor neurons — vestibulospinal reflexes
 autonomic centers — adjust hemodynamic reflexes
 to the cerebellum — coordination and adaptation of vestibular reflexes
• These reflexes stabilize posture and facilitate gait.
 How it works
Semicircular canals
• They respond to angular acceleration and deceleration.
• The three canaIs lie at right angles to each other but the one which
lies at right angles to the axis of rotation is stimulated the most.
• Thus horizontal can al will respond maximum to rotation on the
vertical axis and so on.
• Due to this arrangement of the three canals in three different planes,
any change in posi tion of head can be detected .
• Stimulation of semicircular canals produces nystagmus and the
direction of nystagmus is determined by the plane of the canal being
stimulated.
• Thus, nystagmus is horizontal from horizontal canal, rotatory from the
superior canal, and vertical from the posterior canal.
 Cont’d
Utricle and Saccule
• Utricle is stimulated by linear acceleration and
deceleration or gravitational pull during the
head tilts.
Examination of the ear and clinical auditory
testing
Otoscopy
• Is performed with hand
held otoscope or by
otologist using
otomicroscope
• Auricle is rotated gently
backwards and upwards
• Speculum is slowly
introduced to the ear
canal under visual
guidance
 Contd…
• Normal TM exhibits
three things:

 It reflects light(cone of
light)

 It is semi transparent

 It is mobile
 Contd…
Clinical hearing tests
• goal is to aquire information on the intergrity and side of hearing
by means of simple tests.
• Hearing loss can be of three types:
1. Conductive hearing loss. It is caused by any disease process
interfering with the conduction of sound from the external ear to
the stapediovestibular joint.
2. Sensorineural (SN) hearing loss. It results from lesions
of the cochlea (sensory type) or VIIIth nerve and its central
connections (neural type).
3. Mixed hearing loss. In this type, elements of both conductive and
sensorineural deafness are present in the same ear.
 Contd…
Tuning Fork Tests
 The 512-Hz tuning fork is struck on the examiner’s elbow or knee
1,Rinne Test
• Comparison of bone conduction (stem of the fork firmly pressed on the mastoid)
and air conduction (2–3 cm lateral to the tragus with the tuning fork oriented
parallel to the frontal plane of the skull):
• Normally air conduction is better than bone conduction(rinne positive)
• Conductive hearing loss (negative Rinne test finding),AC < BC
• Sensorineural hearing loss(reduced rinne positive)  BC< AC
 Contd…
2,Weber Test
• Firmly place the stem of the vibrating tuning
fork in the middle of the forehead or on the
teeth
• Lateralization to the ear with a hearing loss :
conductive hearing loss
• Lateralization to the better hearing ear
suggests that the problem in the involved ear
is sensorineural.
Contd…
 Contd…
Audiometric testing
• Audiometry is the measurement of auditory
functions.
• Goals are:
-Type of hearing loss (conductive, sensorineural or
mixed).
-Degree of hearing loss (mild, moderate, moderately
severe, severe, profound or total).
 Pure tone audiometry

• Frequency-It is the number

of cycles per second. The unit
of frequency is Hertz (Hz).
• Pure tone-A single frequency
sound is called a pure tone,
e.g a sound of 250, 500 or
1000 Hz.
• In pure-tone audiometry, we
measure the threshold of
hearing in decibels for
various pure tones from 125
to 8000 Hz.
Pure tone audiometry
• Intensity: It is the strength of sound
which determines its loudness.
• It is usually measured in decibels.
• At a distance of one meter, intensity of
• Whisper= 30dB

• Normal conversation =60 dB

• Shout=90 dB

• Discomfort of the ear=120 dB

• Pain in the ear=130 dB

 Degree of Hearing Loss (WHO classification)

• The following classification

on the basis of pure tone
audiogram….
1. Mild 26 -40 dB
2. Moderate 41-55 dB
3. Moderately severe 56-70 dB
4. Severe 71- 91dB
5. Profound > 91 dB
 Vestibular Assessment
• Goal is to differentiated peripheral vs central vertigo and to suggest specific
pathology.
• Nystagmus is called peripheral, when it is due to lesion of labyrinth or VIIIth
nerve and central, when lesion is in the central neural pathways.
• Assessment of vestibular functions can be divided into two groups:
1. Clinical tests
 Spontaneous nystagmus
 Fistula test
 Hallpike manoeuvre (positional test)
 Romberg test
 Gait
 Past-pointing and falling
2. Laboratory tests
 Caloric test
 Contd…
SPONTANEOUS NYSTAGMUS
• Nystagmus is involuntary, rhythmical, oscillatory movement of
eyes.
• It may be horizontal, vertical or rotatory
Procedure:
• Hold patient’s head with one hand
• Ask patient to look straight ahead at a point several feet away
Look for:
• Nystagmus and note direction
• central or peripheral lesion?
 Contd…
FISTULA TEST
• basis of this test is to induce nystagmus by producing
pressure changes in the external canal which are then
transmitted to the labyrinth.
• Stimulation of labyrinth results in nystagmus and vertigo
• performed by applying intermittent pressure on the tragus
or by using Siegel’s speculum.
HALLPIKE MANOEUVRE (POSITIONAL TEST)
• particularly useful when patient complains of vertigo in
certain head positions
• helps to differentiate a peripheral from a central lesion
Contd…
 Contd…
CALORIC TEST
• basis of this test is to induce
nystagmus by thermal stimulation
of the vestibular system
• patient lies supine with head
tilted 30° forward so that
horizontal canal is vertical
• Ears are irrigated for 40 s
alternately with water at 30°C
and at 44°C
• and eyes observed for
appearance of nystagmus
• COWS
Diseases of the ear
 Diseases of the External Ear
Congenital
Microtia and Anotia
• Microtia is the abnormal
development of the external ear
that results in a malformed
auricle.
• Anotia - complete absence of the
ear.
• associated with other anomalies
50% of the time, esp.
facioauriculovertebral syndromes.
Treatment:
• Reconstructive surgery
• Implantable Hearing Aid
• When?
 Contd…
Preauricular Sinuses
• Commonly seen at the root of
helix.
• Mark the entrance of a sinus
tract near the ear cartilage.
• May produce epithelial lined
cysts or may become infected.
• Usually
asymptomatic…..require no
intervention.
• Complete Excision of the
sinus tract
 Contd…
• Preauricular Tags
• Prominent ('bat') ears
• Cryptotia (the hidden
ear')
 Contd…
Congenital aural atresia
• represents aplasia or hypoplasia of the external
auditory canal (EAC) resulting from failed or aborted
development.
• often associated with other malformations of the
temporal bone, including external(Microtia) &
middle ear.
• Bony atresia occurs more frequently than
membranous atresia.
• Treatment
 Hearing aid
 Reconstruction
 Inflammatory diseases
Otitis Externa:
• It is inflamation of the skin lining the external auditory canal.
• Otitis externa may be divided, on aetiological basis, into:
(I) Infective group
 Bacterial (Localised otitis externa (Furuncle), Diffuse otitis
externa &Malignant otitis externa)
 Fungal (Otomycosis)
 Viral (Herpes zoster oticus, Otitis externa haemorrhogica)
(II) Reactive group
• Eczematous otitis externa
• Seborrhoeic otitis externa
 Contd…
Acute Otitis Externa (AOE)
• “swimmer’s ear”
• Severe pain, worse with ear
movement
• Signs
– Lumen obliteration
– Purulent otorrhea
– Involvement of periauricular soft
tissue
 Contd…
Furunculosis
Is acute localized staphylococal infection of
root of hair follicles.
Lateral 1/3 of EAC(why?)
Severe ear pain,aural fullness
 Contd…
Treatment
• Most common pathogens: P. aeruginosa and
S. aureus
• Four principles
– Frequent canal cleaning
– Topical antibiotics
– Pain control
– Instructions for prevention
 Contd…
Otomycosis:
• Fungal infection of EAC skin
• Most common organisms:
Aspergillus and Candida

• Pruritus deep within the ear

• Dull pain
• Hearing loss (obstructive)
• Canal erythema
• Mild edema
• White, gray or black fungal debris
 Contd…
Treatment:
• Thorough cleaning and drying of canal
• Topical antifungals-Clotrimazole
• Acidifying agents
 Contd…
Granular Myringitis (GM)
• Localized chronic inflammation of tympanic
membrane with granulation tissue.
• Sequela of primary acute myringitis or
previous OE.
• Common organisms: Pseudomonas, Proteus
 Contd…
• Foul smelling discharge from one ear
• Often asymptomatic
• Slight irritation or fullness
• No hearing loss or significant pain
• TM obscured by pus
• No TM perforations
 Contd…
• Careful and frequent debridement
• Topical anti-pseudomonal antibiotics
• Occasionally combined with steroids
• At least 2 weeks of therapy
 Contd…
Bullous Myringitis
• Viral infection Confined to tympanic membrane
• Primarily involves younger children
• Sudden onset of severe pain without fever and hearing
impairment
• Bloody otorrhea (significant) if rupture
• Inflammation limited to TM & nearby canal
• Multiple reddened, inflamed blebs
• Hemorrhagic vesicles
 Contd…
Treatment:
• Self-limiting
• Analgesics
• Topical antibiotics
• Incision of blebs is unnecessary
 Cont…infectous
Necrotizing Otitis Externa(NOE)
• Also called malignant OE
• Potentially lethal infection of EAC and
surrounding structuresTemporal bone &skull
base osteomyletis.
• Typically seen in diabetics and
immunocompromised patients.
• Pseudomonas aeruginosa is the usual culprit.
 Contd…
C/F:
• Poorly controlled diabetic with
Hx of OE
• Deep-seated aural pain
• Chronic otorrhea
• Aural fullness
• Inflammation and granulation at bony cartilage jun.
• Purulent secretions
• Occluded canal and obscured TM
• Cranial nerve involvement
 Contd…
Investigations:
• Computerized tomography used for dx
• Magnetic Resonance Imaging
• Laboratory evidence:ESR
 Contd…
Treatment
• Intravenous antibiotics for at least 4 weeks.
• Local canal debridement until healed
• Pain control
• Use of topical agents:acidic, antibiotic or
antibiotic steroid combination otic drops
• Aggressive diabetic control
• Surgical debridement for refractory cases
 Contd…
Perichondritis/Chondritis
• Infection of perichondrium/cartilage
• Result of trauma to auricle
• May be spontaneous (overt diabetes)
• Pain over auricle and deep in canal
• Pruritus
 Contd…
• Tender auricle
• Induration
• Edema
• Advanced cases
– Crusting & weeping
– Involvement of soft tissues
 Contd…
Rx:
• Topical and oral antibiotics
• Prompt treatment with a broad-spectrum
antibiotic at a high dose.
• presence of subperichondrial abscess requires
drainage.
 Contd…inflammatory
Herpes Zoster Oticus:
• Viral infection caused by varicella zoster.
• Ramsey Hunt syndrome: herpes zoster of the
pinna with otalgia and facial paralysis
• In early stage patients present with burning
pain in one ear, headache, malaise and fever.
• Late (3 - 7 days): vesicles, facial paralysis
 Contd…
• Antivirals-Acyclovir
• Oral steroid-
(10 to 14 days)
• Corneal protection
Non inflammatory diseases and injuries

Cerumen and cerumen impaction

 Produced by the cerumineous and sebaceous
glands
 Forms a protective film, fattyacids, lysozymes,
acidic milleu.
 Self cleaning mechanism of the ear canal.
 Cerumen impaction results from a disturbance
of the normal self cleaning mechanism or
excessive secretion and narrow canal.
 Contd…
Sn&Sx
• pressure sensation, HL, tinnitus
• Dx: yellowish brown or dark material, soft or
hard on otoscopy
Rx: instrumental removal(hooks or currete) or
aural irrigation.
 Contd…
• Hard cerumen can be softened by
pretreatment with H2O2, glycerine
drops, olive oil, or detergents.
• Bacteriologically pure water at 37
oc, syringe with blunt cannula(why
37 0C?).
• Water jet directed
posterosuperiorly
• Followed by otoscopy and hearing
test.
• CIs : positive otologic hx, restless
uncooperative patient, organic
foreign bodies(Vegtable)
 Contd….non inflam
Foreign bodies in the Ear Canal
• present in both children and adults
• Common objects include erasers, pills, batteries, beads,
peas& beans and insects.
• Clinical Findings: present with pain, pruritus, conductive
hearing loss, and bleeding.
• A persistent foreign body may lead to infection and the
formation of granulation tissue.
• Batteries lodged within the EAC, when in contact with
moisture, may cause liquefaction necrosis, low-voltage injury,
or pressure necrosis of the EAC skin or tympanic membrane.
 Contd…
Treatment:
• removal should be done in an atraumatic manner.
• Injury to the EAC is minimized with direct visualization
using the operating microscope and proper
instrumentation (eg, right angle pick, currete, forceps, and
suction) as well as minimizing patient movement.
• In children, general anesthesia is often required.
• Irrigation may help dislodge cerumen or smaller objects.
• 2% lidocaine may be used for the removal of insects both
to achieve topical anesthesia and also to kill the insect.
 Contd…injury
External Ear Trauma
Auricular Hematoma
• Auricular hematoma refers to the
accumulation of blood in the
subperichondrial space, usually
secondary to blunt trauma.
• Edematous, fluctuant, and
ecchymotic pinna with loss of normal
cartilaginous landmarks.
• Early diagnosis and treatment
necessary to minimize cosmetic
deformity.
 Contd
Treatment
• Evacuation of hematomas.
• Irrigation of evacuated hematomas
with topical antibiotics.
• Splinting after drainage prevents the
reaccumulation of hematomas.
• Failure to evacuate the hematoma
may lead to cartilage necrosis and
permanent disfigurement known as
"cauliflower ear."
 Contd…
Traumatic perforation of the TM
• May occur due to foreign bodies usually
pointed objects, and improper cureting or
syringing.
• It can also occur due to direct violence like a
slap or in blast injuries and head injury.
• c/f :
• Pain in the ear, deafness and sometimes blood
stained discharge.
 Contd…
• Rx :
• If patient is seen shortly
after injury,external
canal is packed with a
sterile cotton plug
• No topical drops are
used in the ear
• Perforation usually
heals by itself
 Tumors of external auditory
canal
BENIGN TUMOURS
1. Osteoma.
• It arises from cancellous bone and presents as a single, smooth, bony,
hard, pedunculated benign tumour.
• Treatment is surgical removal.
2. Exostoses.
• They are multiple and bilateral, often presenting as smooth, sessile,
bony swellings in the deeper part of the meatus.
• often seen in persons exposed to entry of cold water in the meatus as
in divers and swimmers.
• small and asymptomatic, no treatment is necessary
• Larger ones, which impair hearing or cause retention of wax and debris-
surgery.
Contd…
 Diseases of the middle ear
Inflamatory
Otitis Media
• refers to an inflammatory process within the
middle ear cleft.
• can be either acute or chronic
• disease that persists for more than 3 months
should be considered as chronic.
• The ET appears to be central to the pathogenesis
of all forms of OM.
 Contd…
• Eustachian tube in the
infant is shorter, wider, and
more horizontal.
• By the age of 7 years the
prevalence of otitis media is
low.
• Three physiologic functions :
(1) pressure
regulation(ventilation)
(2) protection
(3) clearance (drainage)
 Contd…
• Classification
Acute Otitis Media
 Suppurative
 Nonsuppurative
 Recurrent
Chronic Otitis Media
• Suppurative
 With out Cholestatoma (safe)
 With Cholestatoma (unsafe)
• Nonsuppurative
 Otitis media with effusion
 Acute Otitis Media
• AOM is one of the most common infectious
diseases seen in children, with its peak incidence in
the first 2 years of life.
• Most of the population will suffer at least one
episode of AOM at some point in their childhood.
• Recurrent AOM is defined as 3 episodes of acute
suppurative OM in a 6-month period, or 4 episodes
in a 12-month period, with complete resolution of
symptoms and signs between the episodes.
 Contd…
Risk factors
 Contd…
Pathogenesis
• Antecedent viral URTI leads to disruption of eustachian tube
function.
• Inflammation of the middle ear mucosa results in an effusion,
which cannot be cleared via the obstructed eustachian tube.
• This effusion provides a favorable medium for proliferation of
bacterial pathogens, which reach the middle ear via the
eustachian tube, resulting in suppuration.
• The majority of patients develop subsequent bacterial
colonization, and therefore AOM should be considered a
predominantly bacterial infection.
 Contd…
• Streptococcus pneumoniae (40%), Haemophilus influenzae (25–
30%), and Moraxella catarrhalis (10–20%) are the organisms
most commonly responsible for AOM.
• Less frequently: group A streptococci, Staphylococcus aureus,
and gram-negative organisms such as Pseudomonas aeruginosa.
• There are two mechanisms by which the adenoids may influence
OM:
(1) physical obstruction of the eustachian tube when the
adenoids are enlarged and
(2) a reservoir of pathogenic bacteria harbored in the adenoid
tissue, which predisposes the patient to repeated episodes of
AOM.
 Contd…
Symptoms and Signs
• Before the onset of symptoms of AOM, the patient frequently has symptoms
of an URTI.
• Older children usually complain of earache, whereas infants become irritable
and pull at the affected ear.
• A high fever is often present and may be associated with systemic symptoms
of infection, such as anorexia, vomiting, and malaise.
• Otoscopy classically shows a thickened hyperemic tympanic membrane,
which is immobile on pneumatic otoscopy.
• Further progression of the infective process may lead to the spontaneous
rupture of the tympanic membrane, resulting in otorrhea.
• If this occurs, the otalgia and fever often subside. At this stage, it is often not
possible to visualize the tympanic membrane because of the discharge in the
ear canal.
 Contd…
Treatment
 Antibiotic Therapy
• Amoxicillin (80 mg/kg/d given in three divided doses for 10 days)
remains the first-line therapy for AOM.
• In resistant cases, amoxicillin should be given in combination with
clavulanate.
 Adjunctive Therapy
• analgesics and antipyretics
• oral decongestants or antihistamines
Surgical Measures
• Myringotomy-It is incising the drum to evacuate pus and is indicated
when drum is bulging and there is acute pain,incomplete resolution
despite antibiotics with persistent CHL.
 Contd…
Prognosis
• The vast majority of uncomplicated episodes of
AOM resolves without any adverse outcome.
• If this effusion persists for more than 3 months,
then a diagnosis of OME should be made.
• Of patients who develop a perforation of the
tympanic membrane with otorrhea, a small
proportion go on to develop CSOM because of
the failure of the tympanic membrane to heal.
 Contd…
Complications AOM
Extracranial complications
• Tympanic membrane perforation
• Acute mastoiditis
• Petrositis
 infection may extend to the petrous apex giving classic
features of gradenigo’s triad (6th nerve palsy, severe pain in
the trigeminal nerve distribution and middle ear infection)
• Facial nerve palsy
• Labyrinthitis
 Contd…
Intracranial complications
• Meningitis is cited as the commonest
intracranial complication of AOM.
• Extradural abscess
• Subdural empyema
• Sigmoid sinus thrombosis
• Otitic encephalitis (cerebritis)
• Brain abscess
 Contd…
Acute mastoiditis with subperiosteal abcess
• develop some weeks after inadequate treatment of
acute otititis media, when the pathogens are very
virulent or when the patient has low resistance.
• The suppurative process spreads from the middle
ear to the mastoid and causes bone necrosis of the
mastoid air cells.
• The pus can break through outwards through the
mastoid surface behind the pinna or inwards to the
inner ear, dura or facial canal.
 Contd…
Signs and symptoms:
• increasing fever and illness
• increasing pain, especially
over the mastoid area
• tender, fluctuating swelling
and redness over the mastoid
area causing the pinna to
protrude.
• profuse discharge from a
perforation of the ear drum
or a bulging ear drum without
discharge.
 Contd…
Treatment:
• Start with Benzylpenicillin (50,000 units/kg every 6
hours IV) and Chloramphenicol (25 mg/kg every 6
hours IV or IM) and refer to hospital.
• If there is no ENT-surgeon available to perform a
mastoidectomy or when the referral is delayed, then
aspiration with thick needle or an incision and
drainage of the abscess should be done in the hospital.
• administration of IV antibiotics according to the culture
and sensitivity test
 Otitis media with effusion (OME)
• is the accumulation of mucus within the middle ear.
• Persistence of the fluid for > 3 months or longer is
considered chronic.
Causes:
• blockage of the ET by an URTI (rhinitis, sinusitis),
allergic rhinitis, adenoid hypertrophy, nasopharyngeal
tumour.
• OME mostly occurs in children below seven, but also in
HIV-positive adults with lymphadenopathy and re-
growth of the adenoid.
 Contd…
Symptom and signs
• CHL
• feeling of ear pressure,
blocked ear
• sometimes ear-ache
• tinnitus
• retracted ear drum with
middle ear effusion,
sometimes with air bubbles
and a visible fluid level)
• Immobile TM
 Contd…
Treatment:
• Treat upper respiratory tract infections,do not overlook sinusitis.
• Most cases in children resolve spontaneously after some months.
• Refer the patient, if the middle ears don’t clear up and the hearing
impairment persists after 3 months.
• In chronic otitis media with effusion, adenoidectomy with
myringotomy is effective in children.
• Insertion of grommets,depending on the degree of hearing
impairment.
Contd…
Chronic Suppurative Otitis Media (with out
Cholestatoma)
• Result as a consequence of an episode of
AOM with TM perforation.
• After the extrusion of ventilation tubes.
• Traumatic perforations
The most commonly isolated bacteria
responsible for CSOM are P aeruginosa, S
aureus, and the Proteus species.
 Contd…
Symptoms and Signs
• Purulent Otorrhea, which may
be either intermittent or
continuous
• Hearing loss
• Pain is not a usual feature of
CSOM and its presence should
alert the physician to the
possibility of a more invasive
pathology.
• Edematous,hyperemic middle
ear mucosa.
Contd…
 Contd…
Treatment:
keep ear dry
Aural Toilet: mopping, suctioning
Topical Antibiotics
• Topical antibiotics are more effective than systemic antibiotics in the
treatment of CSOM.
• Topical ofloxacin preparations may prove to be as effective as topical
aminoglycosides without the ototoxic potential.
• Aminoglycosides, which are potentially ototoxic.

Systemic Antibiotics
• Systemic antibiotics tend to have a poor penetration of the middle ear
and are therefore less effective than topical antibiotics.
 Contd…
sugery
• Has two main goals
Creating safe middle ear
Restoring hearing
• Types
 Tympanoplasty with/without ossiculoplasty
 Myringoplasty
• Ideally, surgery should be carried out when the
infection has been adequately treated and the middle
ear mucosa is healthy.
 Chronic Suppurative OM(with
Cholestatoma)
• Also called Unsafe COM.
• Cholesteatoma is a sac of keratinized
desquamated epithelium in the middle ear
cleft.
• Can be
Congenital
Acquired
 Clinical features
• The main complaint in
uncomplicated ear is of
discharge and deafness.
• Discharge is purulent ,foul
smelling and scanty in amount,
occasionally blood stained.
• The onset of earache, vertigo,
vomiting and headache signify
the onset of complications.
• Tympanic membrane reveals
perforation.
 Contd…
Treatment aims:
• To make the ear safe by eradicating the disease.
• To prevent reccurence
• Reconstructive surgery of the damaged ossicles and
membrane
Surgeries
Mastoidectomy with/without tympanoplasty
Simple mastoidectomy
Canal wall up mastoidectomy
Canal wall down mastoidetomy
 Bone disorders
Otosclerosis
– Primary metabolic bone disease of the otic capsule(bony
labyrinth) and ossicles.
– characterizedby disordered resorption and deposition of
bone.
– Spongy bone replace the enchondral bone of bony otic
capsule and then to an inactive 'sclerotic' focus consisting of
dense mineralized bone.
– Results in fixation of the ossicles and conductive hearing loss
– May have sensorineural component if the cochlea is involved
– Genetically mediated
• Autosomal dominant
 Contd…
Diagnosis
• Most common presentation
– Women age …..30-40 years
– Conductive or Mixed hearing loss
• Slowly progressive,
• Bilateral (80%)
• Asymmetric
– Tinnitus (75%)
• Family history
– 2/3 have a significant family history
• Audiometry(conductive/mixed hearing loss)
Treatment: hearing aids,stapedectomy
 Tumors
• Tumours of middle ear and mastoid can be divided
into:
1. Primary tumours
(a) Benign: Glomus tumour
(b) Malignant: Carcinoma, sarcoma
2. Secondary tumours
(a) From adjacent areas, e.g. nasopharynx, external
meatus and the parotid
(b) Metastatic, e.g. from carcinoma of bronchus, breast,
kidney, thyroid, prostate and gastrointestinal tract
 Contd…
Glomus tumour
• the most common benign vascular neoplasm of middle ear
 Glomus tympanicum-arise from tympanic plexus
 Glomus jugulare- arise from jugular bulb
Clinical features
• Progressive hearing loss
• Pulsatile tinnitus
• Profuse bleeding
• Red reflex through intact
TM (“Rising sun” appearance)
• Vascular polyp filling the meatus
 Contd…
Treatment
It consists of:
1. Surgical removal.
2. Radiation.
3. Embolization.
 Classification HL

• Causality -Genetic…Hereditary
*(Nonsyndromic(70%)&Syndromic(30%))
-Environmental …….Nonheriditary

• Time of onset -Congenital……. At birth, Late-onset

--Acquired
• Age of onset -Prelingual…… Before speech development
- Postlingual...... After speech development

• Anatomic defect -Conductive…....Dysfunction of outer or ME

-Sensorineural …….Dysfunction of inner ear
-Mixed
 Aproach to a pt with HL
Hx and P/E for Hearing Loss
• Onset:Age at onset
• Sudden , rapidly progressive, gradual
• Intermittent, or continuous
• Unilateral/ bilateral….assymetry
Associated Symptoms
• Tinnitus
• Dizziness or vertigo
• Aural fullness
• Pain
• Allergy symptoms,URTI
• Previous or current drainage from ear
• Quality of drainage
• Actions that change intensity of symptoms
• Distorted auditory perception
 Further History

• Family history of hearing loss

• Occupational noise exposure
• Recreational noise exposure
• Trauma
• Surgical history
• Systemic infections….Meningitis,Syphilis
• Ototoxic medications
• Cancer chemotherapy
• Worsening with pregnancy or oral contraceptive
use…..otosclerosis
 Cont’d
• Antenatal & Perinatal Hx
• Maternal: Drug use, Radiation Exposure,
medical illness….
• Perinatal: instrumental delivery,Asphyxia,LBW,
prematurity, neonatal infections& jaundince…
 Examination

• Complete head and neck examination

• Cranial nerve examination
• Otoscopy with microscope as needed
• Vestibular Assesment
• Tuning fork testing
• Weber test
• Rinne test
 Diseases of the Inner Ear(Cochlea)
• Causes of sensorineural hearing loss most commonly reside in
the cochlea.
• HL classification:
 Differential diagnosis of SNHL
Disorders of Known Etiology
Congenital SNHL
 Genetic Hearing Impairment
o Can be classified as syndromic(30%) and
non syndromic(70%)
• Waardenburg’s Syndrome
– It is transmitted in an autosomal­
dominant fashion and consists of a
constellation of findings, including:
1. Dysto­pia canthorum (lateral displacement
of the medial canthi),
2. Broad nasal root,
3. Heterochromia iridis,
4. A white forelock, and
5. SNHL
 Contd…
• Alport’s Syndrome
– Alport’s syndrome is characterized by interstitial
nephritis, SNHL, and, much less commonly, ocular
manifestations.
– Hearing loss is progressive, usually beginning in
the 2nd decade of life.
• Usher’s Syndrome
– Retinitis pigmentosa and SNHL, responsible for the
majority of Deaf-Blindness cases.
 Congenital Malformations of the Inner Ear

• may involve only the membranous labyrinth(90%) or both the

membranous and bony labyrinths.
1. Cochleosaccular Dysplasia (Scheibe’s Dysplasia)
• the most common inner ear anomaly.
• Affects the cochlea and saccule , the SCCs and utricle are normal.
2. Alexander's dysplasia/Cochlear Basal Turn Dysplasia
• Dysplasia limited to the basal turn of the membranous
cochlea…..high-frequency SNHL
• Residual hearing is present in low frequencies and can be exploited
by amplification with hearing aids.
3.Bing-Siebeman dysplasia.
• There is complete absence of membranous labyrinth.
 Cont’d
3. Complete Labyrinthine Aplasia (Michel’s Aplasia)
• complete absence of bony and memb. labyrinth.
• developmental arrest occurs before the formation of an otic
vesicle, resulting in a complete absence of inner ear structures.

4. Mondini's dysplasia/ Incomplete Partition dys.

• Only basal coil is present or cochlea is 1.5 turns.
 Inflammations of Labyrinth
A. Viral labyrinthitis. Viruses usually reach the inner ear by blood stream
affecting the endolymph .
• SNHL,Vertigo
• Measles, mumps, cytomegalo viruse,HSV….
• Rx-Vestibular sedatives,steroids,bed rest
B.Bacterial/Suppurative labrynthitis: route of invasion can be,
• Otogenic
• Meningogenic
• Present with sudden onset of SNHL and acute vertigo with toxic features.
Treatment
• (a) Bed rest & hospitalization
• (b) Antibacterial therapy
• (c) Labyrinthine sedatives, e.g. prochlorperazine or dimenhydrinate
(Dramamine), are given for symptomatic relief of vertigo.
 Cont’d
4.Syphilis: The mechanism of hearing loss in
syphilis is either a meningolabyrinthitis as seen in
neurosyphilis, or an osteitis of the temporal bone.
• Syphilitic deafness usually occurs during
secondary aquired syphilis,w/c has an abrupt
onset, tends to be bilateral, and is progressive.
• Rx-Crystalline pn /10 days Plus
-Oral steroids.
 Pharmacologic Toxicity
1.Aminoglycosides
• Most common offending agents
• Kanamycin, tobramycin,amikacin, neomycin, are more
cochleotoxic > vestibulotoxic.
• Streptomycin and gentamicin, are more vestibulotoxic >
cochleotoxic.
• Well-defined risk factors for aminoglycoside-induced ototoxicity
include
 presence of renal disease;
 longer duration of therapy;
 increased serum levels
 advanced age; and concomitant administration of other ototoxic
drugs, particularly the loop diuretics.
 Cont’d
2.Ototopical Preparations
• can cause damage to the cochlea by absorption through oval and round
windows.
• Topical preparations containing neomycin, gentamicin, and tobramycin
have long been used for treatment of otitis externa and COM.
3.Loop Diuretics
• Ethacrynic acid and furosemide
• Reversible SNHL
• Alter metabolism in the stria vascularis resulting in alteration of
endolymphatic ion concentration.
• Risk factors for loop diuretic–induced ototoxicity include
(1) renal failure,
(2) rapid infusion, and
(3) concomitant aminoglycoside administration.
 Contd…
4.Antimalarials(Quinine):
• Tinnitus and sensorineural hearing loss,w/c usually is transient & appear
with prolonged use.
• Permanent hearing loss occur with large doses.
5. Salicylates:Aspirin
• Tinnitus and SNHL.
• The hearing loss is dose-dependent and reversible (On discontinuation of
the drug, hearing returns to normal within 72 hours.)
6. Cytotoxic drugs
• Cisplatin:
• The incidence of hearing loss children (84% to 100%). Children seem to
be significantly more susceptible to ototoxicity.
• Bilateral,and irreversible.
 Contd…
 Trauma
 Labriynth Concusion
 Perilymphatic Fistula
 Noise-Induced Hearing Loss- >85 db for 8 hrs/day
 Neurologic Disorders
 Multiple Sclerosis
 Benign Intracranial Hypertension
 Hematologic Disorders
 Immune Disorders-Cogan’s syndrome, Wegener’s
granulomatosis
 Neoplasms-Acoustic Neuroma
 Contd…
Disorders of Unknown Etiology
 Presbycusis
• Age related decreased peripheral auditory sensitivity >65 years
• Bilateral and slowly progressive
• typically is worse for high frequencies
 Meniere’s Disease and Endolymphatic Hydrops
• fluctuant SNHL, tinnitus, episodic vertigo, and aural fullness
 Idiopathic Sudden sensorineural hearing loss (ISSNHL)
• an ENT emergency
• Definition: 30 dB or greater SNHL over at least three contiguous
audiometric frequencies occurring within 3 days or less.
• Idiopathic: Exclusion of specific cause based on history, clinical
examination, basic investigations ± magnetic resonance imaging scan.
Treatment of sensorineural hearing loss

 Known causes-treat the cause if treatable

 Hearing aids
 Cochlear implantation
 Vestibular disorders
• Vertigo is the illusion of motion, either of self
or of the environment.
• Represent 5-10 % of all patients seen in
general practice.
• Categorized into two main groups:
1. Peripheral Vertigo
2. Central Vertigo
 Peripheral vertigo
 Due to dysfunction of one of vestibular end organs
 Asymmetry of input to vestibular nuclei
 Associated with nausea, vomiting and diaphoresis
DDx
– Benign paroxysmal positional vertigo (BPPV)
– Vestibular neuritis
– Labyrinthitis
– Meniere’s disease
 Contd…
BPPV
• Age = 60- 70
• Etiology is unknown but sometimes it is associated with
head trauma.
• Otoliths(otoconial debris) become detached from hair cells in utricle
• Inappropriately enter the posterior semicircular canal
• Occurs with position of head
• Turning over in bed
• Looking up
• Bending over
• characteristic clinical sign of BPPV is nystagmus following a
Dix-Hallpike manoeuvre
 Contd…
• Treatment:
Canalith repositioning maneuver(Epley)
• Moves otoliths out of the posterior
semicircular canal and back into utricle where
they belong.
 Contd…
Vestibular neuronitis
• Acute unilateral loss of peripheral vestibular function
• Associated with vertigo, nausea,vomiting and nystagmus.
• Worsened by head movement
• Occurs in healthy young to middle-aged adults often
after respiratory tract infections.
• Self-limiting
Treatment
• Bed rest
• Vestibular suppresants -Antihistamines
 Contd…
Meniere’s disease
• Meniere's Disease, also called endolymphatic hydrops, is a
disorder of the inner ear where the endolymphatic system is
distended.
– Characterized by triad of:
• episodic vertigo
• tinnitus
• flunctuating hearing loss (sensorineural)
– Chronic relapsing illness
– Due to a build-up of endolymphatic pressure in the
labyrinth(Endolymphatic hydrops)
 Contd…
Treatment
• aimed at the reduction of its associated
symptoms
 Dietary Modification and Diuretics
 best initial therapy
 Vasodilators
 betahistine, an oral preparation
 Symptomatic Treatment
 antivertiginous medications, antiemetics, sedatives
 Central Vestibular Disorders
• pathologies occurring central to the labyrinth and vestibular nerve.
• 10% to 20% complaints of dizziness.
 Contd…
Physiologic Dizziness
• phenomena that occur in normal persons as a result
of physiologic stimulation of the vestibular, visual, or
somatosensory system.
Motion sickness
• is a common form of physiologic dizziness.
• main symptoms are dizziness, fatigue, pallor, cold
sweats, and finally nausea and vomiting.
• a mismatch among sensory signals causes
disorientation, imbalance, and vegetative symptoms
 Contd…
Treatment:
• During riding a car being in the back seat or
reading may make symptoms worse than sitting
in front and looking off into the distance.
• Minimizing conflicting sensory inputs by
restricting unnecessary head movement.
• Anti–motion sickness drugs are aimed at
modulating the histaminic, cholinergic, and
noradrenergic neurotransmitters.
 Facial nerve disorders
• The facial nerve is
composed of motor,
sensory and
parasympathetic fibres.
• The course of the facial
nerve can be divided
into
 Intracranial
 Intratemporal and
 Extratemporal portions.
 FN(Cont’d)
 Intratemporal segment FN
branches
 greater superficial petrosal
nerve- Lacrimal glands
 Chorda tympani Nv-
Submandibular and
sublingual glands,special
taste fibers to the anterior
2/3 of the tongue.
 Contd…
• The facial nn exits the skull base through stylomastoid
foramina
• The nerve then divides within the parotid gland into its
temporofacial and cervicofacial branches.
• Generally five main branches of the nerve can be identified:
 Temporal
 Zygomatic
 Buccal
 Mandibular
 Cervical
 Patient evaluation
 Hx of the onset & course of palsy,
 Unilateral / bilateral, Hx of recurrence, duration
 Otologic symptoms, disease & previous ear surgery.
 Trauma
 Tick bites (borellosis)
 Systemic Illness:Autoimmune dss,cancer,
Neurologic Disease,Diabetes….
 Disturbances of lacrimation(dryness, crocodile
tears;gustatory lacrimation) and altered taste.
 Contd…
• General otolarygologic examination
* Otologic Exam
* Parotid Gland
* Function of other Cranial Nvs
• Testing Motor Function of FN
o -Wrinkling the forehead, forced eye
closure
o -flaring the nostrils and wrinkle the
nose
o -forcibly show the teeth &
attempting to blowout the cheeks.
• *Supranuclear Vs Infranuclear
Lesions

• Upper part of FN nucleus which

innervates forehead muscles
receives fibres from both the
cerebral hemispheres, while the
lower part of nucleus which
supplies lower face gets only
• crossed fibres from one
hemisphere.
• The function of forehead is
preserved in supranuclear lesions
because of bilateral innervation.
* Supranuclear Vs Infranuclear Lesions
DDX
 Bell’s Palsy
• Spontaneous Idiopathic Facial Paralysis
• Most Common cause of AFP
(1) paralysis or paresis of all muscle groups of
one side of the face;
(2) sudden onset;
(3) absence of signs of CNS disease &
(4) absence of signs of ear or CNS disease.
 Contd…
History
• Sudden onset…..Occurs over 24-48
hours
• Evolution over 2-3 weeks
*Rule out neoplasm if evolution
past 3 weeks
• Other Sy: Dysgeusia,Decreased
lacrimation,
• P/E: Peripheral LMN palsy
 Contd…
Treatment:
• Steroids
• Antivirals-acyclovir
• Surgical decompresion
Prognosis
 Incomplete FP : 95% to 100%recover with no
sequelae
 Complete FP :> 85% some return of facial tone
within 3 weeks
 Traumatic Facial Paralysis

o Second most common cause of FN paralysis

behind Bell’s Palsy
Represents 15% of all cases of FN paralysis
o The most common causes of intratemporal facial
nerve injury are:
• Temporal bone fracture,
• Penetrating injuries (typically from a bullet) and
• Iatrogenic injuries-
Parotidectomy,Mastoidectomy
 Contd…
• Complete paralysis
– Likely nerve transection
– Surgical exploration
• Incomplete FP or delayed loss of function
-- High dose steroids- Predinisolone 1mg/kg for
10 days
 Complications of FN Paralysis
• Incomplete recovery
• Exposure keratitis….
Artificial tears ,Ointments,
Eye glass
• Contractures
-Results from fibrosis of
atrophied group of muscles
 Contd…
• Spasm:
- involuntary twitching and contraction of one side
of the face
-Result of faulty regeneration of fibres
-usually painless
• Crocodile tears/gustatory lacrimation:
-Due to faulty regeneration of parasympathetic
fibres which now supply lacrimal gland instead of
the salivary glands.
 Temporal Bone Trauma
• When the head trauma is of sufficient
magnitude to fracture the skull, 14% to 22% of
injured patients sustain a temporal bone
fracture.
• 31% of the fractures resulted from motor
vehicle accidents.
• Male to Female ration is 3 : 1, which is
attributed to involvement in riskier activities.
 Contd…
• Isolated temporal bone trauma is very rare and evaluation of
pts starts by assessing the emergency ABC of life.
• The auricles are inspected for lacerations and hematomas.
• The ear canal is inspected for fractures along the roof, CSF
otorrhea, the degree of hemorrhage, and the presence of
brain herniation.
• The integrity of the tympanic membrane is assessed*
 Contd…
• Neurotologic examination .
• Hearing assessed after patient stabilization at the
bed side.
• Head CT is usually done for severe head injury for the
impression of intracranial bleeding.
– HRCT is indicated in the presence of facial
paralysis, CSF fistula, or suspected vascular injury.
 Contd…
• The common complications include
– Facial nerve paralysis
– Hearing loss
– CSF fistula
– Stenosis of the ear canal,
– Cholesteatoma formation and
– Vascular injuries